Laserfiche WebLink
11.If thls dalm involves a vehlde actlden4ro111slon,provide your vehicle Inlormatlon:_!Y(,� . <br /> M!e Na. MaAr Nodel Year <br /> O �rr lamc DiivriS(lmnsc Na Vnhkle Pmcr(tJ fl dJ/vcnf/mm ddvrrJ <br /> � <br /> O� eJlnsuianrc[ompany oAoncl/o. PoUry/lo. <br /> �2 Names,addresses and teiephonc numbers of all persons Invotved In ur tvilness to Ihls Incident: <br /> vi n �- �. �_1�'25 ��,� � �',�rc�nzl , r.�9 q�zp7 <br /> �,-- �l - � - �-�-�=5 � fr g . — rr.i �,l.a�_qBzQ! <br /> 13.Names,addmsses and Ieiephone numbers of all qty of Everett empioyees having knowledge ahout lhls Inddent: <br /> nrmn� _ <br /> � <br /> 14. Names, addresses and lelephone num6ers of aif Indivlduals not already Identifieci In Ni2 and N13 above who have knowicdge <br /> regarding Ihc Ilabltity Issues Involved In lhls Inddent, or knowledge of lhe ClalmanCs resulUng damages Please Indude a bdef <br /> descdpllon as to lhe nature and extent of wch person's knov+led9e/. Allach addlUanal sheets If nece sary. <br /> �7 ^ C�� <br /> _ �r /�� <br /> J /Vl Q� <br /> 2 c�V�✓ <br /> 15, . hc keQ or da . I e t of•prope ohs��meaiE�=Dh !em entel inJudes. �Attach <br /> addlllonal sheets II necessa . <br /> ��� — ��' �orw�. g ?91, l3. <br /> ' Y' . <br /> �� '� 3 � <br /> _ Dr <br /> � ��- 6. <br /> 16.Has Ihis Inddcnt hcen repoded to la�v enfarcc en[,safcry or secudty persohn_q If so,when and to x�hom? <br /> � � __C(�,�o_�A��_u�c��3����y�� -��'nI <br /> 1 , r i s, d i .c n tcic.hMr num etY c c providcr . �Atlac�c lp es of all mcdlwl rc blLi SY� n s�.'`^`^�11 <br /> —Y�M" / <br /> 1B.Please altach Joaments lhat suppod lhe clatm's alle9atlons, <br /> 19.I clalm damages from the City oF Everett In the sum of 4__. �_I-,-�—�� <br /> This dalm form mvst be sl9ned 6y elther the Clalmant or on 6chaif of Ihe Clalmanl by an attmney-IndaU who holds a wdtten power of <br /> attomey for[he Ualmant,or by an attomcy at�law admlt[ed to pradlcc In lhc SWte of Washington,or by a couR•appmved guardlan or <br /> guartllan ad Otem. <br /> I dedare under penalry of perJury under the laws of lhe SWM ol Washlnqton Ihat the fore9oing Is true and correct. <br /> � �d,�,��, �v�_vn�t� ��,� <br /> 51 atura of lalm nt Da[a Jr— Place signe�l (dty and state) <br /> Fev.OT109 <br /> i ,�+ !' <br /> a� •r <br /> �._.- <br />